Eosinophilic fasciitis: a rare skin sclerosis

A Case Report of Atypical Migratory Shulman Syndrome

Eosinophilic fasciitis (EF), or Shulman syndrome, is a rare connective tissue disorder characterized by symmetrical and painful swelling and with progressive thickening of the skin and soft tissues with the potential involvement of internal organs such as the pleura, pericardium, and kidneys. Patients may also present with fever, myositis, arthritis, neuropathies, and other systemic symptoms. This case report describes a unique multifocal asynchronous soft tissue involvement in Shulman syndrome in a 39-year-old patient, highlighting clinical presentation, histopathological findings, differential diagnoses, treatment modalities, and patient outcomes. Atypical migratory skin lesions must be considered in the diagnosis of EF. Timely recognition of the disease is crucial for optimal treatment and better patient outcomes.

Immunologic and nonimmunologic sclerodermal skin conditions - review

Scleroderma-like cutaneous lesions have been found in many pathological conditions and they have the clinical appearance of sclerotic or scleroatrophic lesions. Affected skin biopsies described histopathological changes similar to those of scleroderma located strictly on the skin or those of systemic sclerosis. These skin lesions can be found in inflammatory diseases with autoimmune substrate (generalized morphea, chronic graft versus host disease, eosinophilic fasciitis), tissue storage diseases (scleredema, scleromyxedema, nephrogenyc systemic fibrosis, systemic amyloidosis), metabolic diseases (porphyrya cutanea tarda, phenylketonuria, hypothyroidism, scleredema diabeticorum), progeroid syndromes. Given the multiple etiologies of sclerodermal lesions, a correct differential diagnosis is necessary to establish the appropriate treatment.

Functional and structural characteristics of HLA-B*13:01-mediated specific T cells reaction in dapsone-induced drug hypersensitivity

BACKGROUND

Severe cutaneous adverse drug reactions (SCARs) are a group of serious clinical conditions caused by immune reaction to certain drugs. The allelic variance of human leukocyte antigens of HLA-B*13:01 has been strongly associated with hypersensitivities induced by dapsone (DDS). T-cell receptor mediated activation of cytotoxic T lymphocytes (CTLs) has also been suggested to play an essential role in pathogenesis of SCARs. However, HLA-B*13:01-DDS-TCR immune synapse that plays role in drug-induced hypersensitivity syndrome (DIHS) associated T cells activation remains uncharacterized.

METHODS

To investigate the molecular mechanisms for HLA-B*13:01 in the pathogenesis of Dapsone-induced drug hypersensitivity (DDS-DIHS), we performed crystallization and expanded drug-specific CTLs to analyze the pathological role of DDS-DIHS.

RESULTS

Results showed the crystal structure of HLA-B*13:01-beta-2-microglobulin (β2M) complex at 1.5 Å resolution and performed mutation assays demonstrating that I118 or I119, and R121 of HLA-B*13:01 were the key residues that mediate the binding of DDS. Subsequent single-cell TCR and RNA sequencing indicated that TCRs composed of paired TRAV12-3/TRBV28 clonotype with shared CDR3 region specifically recognize HLA-B*13:01-DDS complex to trigger inflammatory cytokines associated with DDS-DIHS.

CONCLUSION

Our study identified the novel p-i-HLA/TCR as the model of interaction between HLA-B*13:01, DDS and the clonotype-specific TCR in DDS-DIHS.

Eosinophilic Fasciitis of Wrists with a Positive Prayer Sign

Eosinophilic fasciitis (EF) is an uncommon disease of unknown etiology and is characterized by inflammation and thickening of the muscular fascia and subcutaneous tissue. The patients often have peripheral eosinophilia, increased erythrocyte sedimentation rate, and hypergammaglobulinemia. In EF, the skin of the hands and feet are generally spared. Herein we present a case of EF of the wrists with a positive prayer sign and good response to corticosteroid and methotrexate. It is important to emphasize that a positive prayer sign might be the first symptom of EF. The combination regimen of systemic corticosteroids and methotrexate is recommended.

Eosinophilic fasciitis

Eosinophilic fasciitis is a rare sclerodermiform syndrome of unknown etiology. It is characterized by the thickening of the muscular fascia and subcutaneous tissue, with a variable infiltration of eosinophils. Peripheral eosinophilia, poly or monoclonal hypergammaglobulinemia and increased erythrocyte sedimentation rate can be seen. Clinical features begin acutely, with local edema and a painful and symmetrical stiffening of the limbs, progressing rapidly to fibrosis, which can limit joint movements. Some cases have a history of strenuous physical exercise or trauma. The diagnosis is confirmed by a deep skin biopsy. Glucocorticoids in high doses is the treatment of choice. We report a typical eosinophilic fasciitis case with peripheral eosinophilia and dramatic response to pulse therapy with methylprednisolone.

Eosinophilic fasciitis with subjacent myositis

INTRODUCTION

Eosinophilic fasciitis (EF) is a rare disorder that can present with muscle symptoms that mimic other neuromuscular diseases.

METHODS

We report the case of a 43-year-old woman with chronic muscle aches, tightness, and stiffness with hypertrophied, well-defined muscles despite physical inactivity, and thickened skin with reduced elasticity and discoloration.

RESULTS

Except for mild peripheral eosinophilia, laboratory studies, including blood count, electrolytes, paraneoplastic panel, muscle enzymes, thyroid function, and serum protein electrophoresis, were normal. Nerve conduction studies and needle electromyography were normal. Magnetic resonance imaging of the thighs demonstrated superficial and deep fascial thickening with T2 hyperintensity and post-gadolinium enhancement. Fascial and muscle biopsy demonstrated an inflammatory exudate in the perimysium and endomysium with fragmented perimysial connective tissue and thickened, inflamed fascia. EF was diagnosed. The patient was treated with methotrexate and prednisone followed by improvement of muscle stiffness and tightness.

CONCLUSION

EF should be considered when patients present with muscle pain or enlarged muscles. Muscle Nerve 56: 525-529, 2017.

Finger stiffness or edema as presenting symptoms of eosinophilic fasciitis

To investigate the clinical features and finger symptoms of eosinophilic fasciitis (EF), we reviewed five patients with EF. The chief complaint was pain, edema and/or stiffness of the extremities. The distal extremities were affected in all patients, and there was also proximal involvement in one patient. One patient had asymmetrical symptoms. All four patients with upper limb involvement had limited range of motion of the wrist joints, and three of them complained of finger symptoms. Two of these three patients showed slight non-pitting edema of the hands, and the other one had subcutaneous induration of the forearm. All four patients with lower limb symptoms had limited range of motion of the ankle joints, and two showed edema or induration of the legs. Inflammatory changes in the joints were not detected in any of the patients. Two patients displayed neither objective induration nor edema, and two patients had muscle tenderness. In conclusion, finger symptoms of patients with EF might be caused by fasciitis of the forearms, which leads to dysfunction of the long finger flexors and extensors as well as slight edema of hands. Limited range of motion of wrist and/or ankle joints indicates sensitively distal muscle dysfunction caused by fasciitis.